We provide the real, FDA-approved Latisse ® to our patients safely, inexpensively and as conveniently as possible. Since Latisse ® is a prescription product, we must review your medical history information to ensure Latisse ® is right for you.

All medical information is kept strictly confidential and will not be released without your expressed, written consent, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191).

Medical History Form

Please complete the following medical history form and click on the "Submit Form and Place Order" button at the bottom of the form to place your order.

Your form will be reviewed within 24 hours. We will then inform you of your approval to use Latisse® and release your order.
    There are currently no adequate and well-controlled studies of bimatoprost ophthalmic solution 0.03% administration in pregnant and/or nursing women. As such, and to ensure our patients and their children's safety, we will not prescribe Latisse® via the Latisse.MD website to pregnant or nursing mothers. If you are pregnant or breast feeding we recommend using Latisse® only under the close supervision of your OB/GYN.
  • Your electronic signature above is your signed acceptance that all information submitted is true and correct to the best of your knowledge and that you accept USPS's delivery confirmation as proof of Latisse® delivery to you unless you purchase insurance when placing your order.

AFTER SUBMITTING YOUR FORM AND PLACING YOUR ORDER PLEASE CHECK YOUR EMAIL FOR CONFIRMATION. BE SURE TO CHECK YOUR JUNK EMAIL FOLDER IF YOU DO NOT IMMEDIATELY RECEIVE AN EMAIL FROM SERVICE@LATISSE.MD.

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